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  • Woc Fistula Enterocutan - Ledika Alma Novitasari - Profesi Ners

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    An enterocutaneous fistula developed in a patient after an appendectomy where the incision wound did not fully close. This led to leakage of intestinal and stomach contents through the skin, causing nutritional deficits, dehydration, diarrhea and risk of infection. Interventions were implemented to manage pain, prevent infection, support nutrition and sleep, and treat skin integrity issues. The goals were to reduce complications and prove the interventions were effective by monitoring outcomes such as decreased pain levels, infection rates, and improved nutritional status, sleep patterns and skin integrity.

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    WOC FISTULA ENTEROCUTAN_LEDIKA ALMA NOVITASARI_PROFESI NERS

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    An enterocutaneous fistula developed in a patient after an appendectomy where the incision wound did not fully close. This led to leakage of intestinal and stomach contents through the skin, causing nutritional deficits, dehydration, diarrhea and risk of infection. Interventions were implemented to manage pain, prevent infection, support nutrition and sleep, and treat skin integrity issues. The goals were to reduce complications and prove the interventions were effective by monitoring outcomes such as decreased pain levels, infection rates, and improved nutritional status, sleep patterns and skin integrity.

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    8 views2 pages

    Woc Fistula Enterocutan - Ledika Alma Novitasari - Profesi Ners

    Uploaded by

    mocysiblackcat
    An enterocutaneous fistula developed in a patient after an appendectomy where the incision wound did not fully close. This led to leakage of intestinal and stomach contents through the skin, causing nutritional deficits, dehydration, diarrhea and risk of infection. Interventions were implemented to manage pain, prevent infection, support nutrition and sleep, and treat skin integrity issues. The goals were to reduce complications and prove the interventions were effective by monitoring outcomes such as decreased pain levels, infection rates, and improved nutritional status, sleep patterns and skin integrity.

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    © All Rights Reserved
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    of 2

    LEDIKA ALMA NOVITASARI

    PROFESI NERS KI
    P1337420923151
    WOC FISTULA ENTEROCUTAN

    Stomach hurts Appendicitis appendectomy The incision wound


    is not completely
    closed

    The incision wound infection


    laparotomy
    always oozes fluid
    (seeps)

    Leakage at the Definition


    Nutritional Deficit related to suture wound Signs and symptoms
    Enterocutaneous fistula (ECF)
    excretion of juices food from
    the fistula, the absorption 1. Dehydration is an abnormal connection that
    capacity is inadequate (D.0019) FISTULA
    develops between the
    ENTEROCUTAN 2. Malnutrition
    intestinal tract or stomach and
    3. Diarrhea the skin. As a result, the
    contents of the stomach or
    Intestinal fluid comes
    Stool, pus comes out intestines leak onto the skin.
    out through the skin

    The complexity of an enterocutaneous


    fistula depends on amount of expenditure.
    High risk of infection Infection of the
    is associated with a.Low: 200 ml/24 hours
    suture wound b.Moderate: 200-500 ml/24 hours
    reduced power body
    c. High: 500 ml/24 hours
    resistance, surgical
    process (D.0142)
    VAC installed with a Impaired skin/tissue Complications that can
    Pain around the integrity related to
    colostomy bag with a occur in patients with fistula
    wound decreased mobility
    pressure of 15Kpa (D.0192) enterocutaneous:

    a. Malnutrition
    Intervention: Pain Management b. Dehydration
    Chronic Pain associated Disturbed sleep (I.08238)
    with mucosal irritation, patterns related to pain c. Skin problems
    inflammatory processes (D.0055) The results criteria to prove that
    the level of pain has decreased d. blood poisoning
    (D.0078)
    are:
    1. Reduced pain complaints
    Intervention: Nutrition Intervention:Infection 2. Feelings of depression Intervention: Sleep Support
    Management (I.03119) Prevention (I.14539) decrease (I.05174)
    3. Grimacing decreases
    The outcome criteria to The outcome criteria to The results criteria to prove that
    4. Decreased anxiety
    prove that nutritional prove that the infection rate the level of sleep disturbed has
    5. The ability to complete
    status has improved are: is decreasing are: decreased are:
    activities increases
    nutritional status improves
    1.Fever decreases Pain Levels Decreased L.08066
    1. Complaints of difficulty
    1. The portion of food 2.Redness decreases sleeping have decreased
    consumed increases 3.Pain decreases 2. Complaints often decrease
    2.Body weight improves 4.Swelling decreases 3. Complaints of dissatisfaction
    3. Body mass index (BMI) 5. White blood cell levels with sleep have decreased
    Intervention: Skin Integrity
    improves L.03030 improve 4. Complaints about changing
    Treatment (I.11353)
    Infection Rates Decreased sleep patterns have decreased
    L.14137 The result criteria to prove that the 5. Complaints of not getting
    level of impaired skin integrity has enough rest decreased
    decreased are:
    Improved Sleep Patterns L.05045
    1. Decreased tissue damage
    2. Decreased skin layer damage
    Skin/tissue integrity improves
    L.14125

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